Since the first successful valve replacement using the caged-ball valve, numerous engineering modifications have been made to enhance hemodynamic performance and durability of the artificial valve. Currently, various types of artificial valves are available are implemented depending on patient characteristics and need for surgical valve replacement. Bioprosthesis has the advantage of a low thromboembolism rate without warfarin, however, structural valve deterioration is a disadvantage. On the other hand, a mechanical valve has superior durability compared to the bioprosthesis. However, mechanical valve use requires life-long anticoagulant therapy. Recently a catheter-delivery heart valve, classified as a bio-prosthesis, has been implanted in patients outside Japan.
It is inevitable that the patients with abdominal aortic aneurysms (AAA) will face a life threatening crisis if they do not undergo surgical treatment. In 1952 the first synthetic synthetic graft of Vinyon -N implantation was performed by Arthur Voorhees. Knitted Dacron fabric, a polyester polymer, was developed by Michael DeBakey and associates in Houston and has been an almost ideal graft material even to this day. Dacron grafts have undergone several improvements since 1952. From the 1960s to 1990s Dacron and Teflon grafts have been implanted in patients with AAA with a 95% success rate. In 1991, Parodi first reported the successful endovascular repair of an AAA. The design of stentgrafts was substantially improved, giving in better stability. The stentgraft system is an innovative device designed to be a minimally invasive treatment option for high risk patients with AAA. In the 2000s endovascular aneurysm repair (EVAR) and thoracic endovascular aneurysm repair (TEVAR) have been developed as standard procedures for AAA and descending thoracic aneurysms.
In the last decade, the therapeutic strategy for patients with peripheral arterial disease (PAD) has changed markedly after the introduction of endovascular treatment and surgical approaches. In particular, endovascular treatment of iliac occlusive disease is an established treatment modality, although the treatment of infrainguinal lesions remains controversial. The trans-Atlantic Inter-Society Consensus II (TASCII) document of 2007 recommended endovascular treatment in patients with TASCII types A and B lesions and surgical bypass in patients with TASCII types C and D lesions. Most patients with critical limb ischemia (CLI) are in poor general condition, and the goal of revascularization in CLI is not only limb salvage but preservation of life. Currently, bypass surgery is the optimal revascularization procedure for bypass-applicable CLI patients. Improvements in endovascular treatment and expansion of its indication may apply especially to CLI patients who are in poor general condition. Carotid disease is an important cause of stroke and may cause 10-20% of all ischemic strokes. The choice of revascularization strategy in tese cases should be based on the surgical risk profile of the patient and the institution′s expertise. Carotid artery stenting is particularly beneficial for patients at high surgical risk, e.g. surgically inaccessible lesions, radiation-induced carotid stenosis, prior ipsilateral radical neck dissection, and prior carotid endarterectomy. Results of medical treatment continue to improve, but there is still the need for more experience which will aid in establishing treatment strategies for severe carotid disease.
Endovascular treatments for visceral artery aneurysms (VAAs) and renal artery stenosis (RAS) have increased rapidly in recent years and endovascular approaches have supplanted surgical approaches for revascularization. A number of endovascular treatment studies have reported prevention of VAA rupture and clinical benefit for patients with RAS. This review summarizes the current status of endovascular treatment of VAAs and RAS.
Deep vein thromboses (DVTs) cause significant morbidity and mortality in the general population. Oral anticoagulation therapy may reduce thrombus propagation but does not cause clot lysis and therefore does not prevent post-thrombotic syndrome. Catheter-directed thrombolysis (CDT) can be used to treat DVTs as an adjunct to medical therapy, but there is no consensus defining exact indications. Current evidence suggests that CDT can reduce clot burden and DVT recurrence and consequently prevents the formation of PTS compared to systemic anticoagulation. Limb-threatening thromboses may also be treated with CDT, although the subsequent mortality remains high. A number of randomized controlled trials are currently underway to compare the longer-term outcomes of CDT with anticoagulation alone. Initial reports suggest that venous patency and valvular function are better maintained after CDT. The reported short-term outcomes following catheter-based intervention for DVT are encouraging in selected patients. Further evidence is required to establish long-term benefits and cost-effectiveness.
Percutaneous coronary intervention (PCI) is now challenging coronary artery bypass grafting (CABG) as the gold standard of care for patients with multi-vessel disease. However, the application of PCI to these patients has been limited by restenosis. Up to the beginning of 2000s, many large-scale, randomized trials addressed this issue by comparing CABG to PCI with balloon angioplasty or bare-metal stents. These trials took place not only in western countries but also in Asian countries. These studies reported similar rates of death and myocardial infarction in both groups, while the need for revascularization remained significantly lower in the CABG group. PCI with drug-eluting stent (DES) is safe and greatly decreased the restenosis rates. Indication of PCI has been extended by using DES. Therefore, PCI has been chosen as the treatment for patients with multi-vessel disease, left main disease and the other complex lesions rather than conventional bypass surgery. Therefore, in this report, the present situation of PCI and the future prospects for PCI in Japan are described. Finally, it might be important for interventional cardiologists and cardiovascular surgeons to discuss revasucularization strategies for each patient with coronary artery disease.
Clinical application of neuro-endovascular therapy was first reported in 1974 by Servineko et al., who used a detachable balloon to treat a symptomatic carotid cavernous fistula. The fistula was occluded by the detachable balloon and the patient′s symptoms improved. Embolization of aneurysms was greatly advanced by the introduction of the Guglielmi detachable coil, and since then, remarkable progress has been achieved in endovascular treatment of aneurysms. Verification of the efficacy of neuro-endovascular therapy for ruptured aneurysms, such as coil embolization for intracranial aneurysms, has been demonstrated by the International Subarachnoid Aneurysm Trial (ISAT). ISAT results indicate the vital role played by this therapy in improving the treatment of subarachnoid hemorrhage. Recently, new instruments for neuro-endovascular therapy have been approved for clinical use in Japan. These instruments include vascular reconstruction devices (VRD) such as the Enterprise self-expanding stent system for unruptured wide-neck aneurysms larger than 7 mm, Onyx (ethylene vinyl alcohol) liquid material for embolization of arteriovenous malformations, and the Merci retriever for mechanical removal of emboli in acute stroke within 8 hours of onset. Furthermore, innovative diagnostic modalities, such as flat panel detectors and three-dimensional digital subtraction angiography (3D-DSA) have contributed to both the development and safety of neuro-endovascular therapy. Advances in device and diagnostic technology have made it possible to treat even difficult cases. This review summarizes current neuro-endovascular treatment for neurosurgical diseases.
We report our experience in performing mitral annuloplasty using Physio ring-II, a prosthetic valve ring modification of the Physio ring, which has semi-rigid double saddle shaped structures. Subjects consisted of 4 patients who underwent mitral annuloplasty using Physio ring-II. There were no incidences of operative death or postoperative complication, and the postoperative NYHA improved to Class I in all cases. Postoperative mitral valve regurgitation was trivial in 2 cases, and not observed in 2 cases. Postoperative LDH was in the normal range in all cases, and there were no cases where hemolysis was suspected. Physio ring-II, a prosthetic valve having a structure of physiological valve ring, was considered to increase the possibility for mitral annuloplasty.
Pulmonary hamartomas are the most common benign lung tumors, are usually a solitary tumor, and occur without cystic changes in the lung tissue around the tumor. A 20-year-old woman was admitted to our hospital due to pulmonary cystic and multiple solid lesions after detection by chest radiograph during a health check up. This lesion was removed under thoracoscopic assisted surgery. It was histologically diagnosed as a multiple pulmonary chondromatous hamartoma with cystic degeneration. The postoperative course was uneventful, and the patient was discharged from the hospital on the seventh day after operation.
A 78 year-old female had a history of tako-tsubo cardiomyopathy two years ago. She was admitted to another hospital with prolonged chest pain after she felt mental stress at home. Abnormal electrocardiogram findings of ST elevation in leads V1-2 and slightly elevated troponin T were found. Coronary angiography revealed normal coronary arteries and multivessel coronary vasospasm by acetylcholine advocate test. Left vetriculography showed typical apical ballooning pattern with akinesis of the left ventricular apex and hyperkinesia of basal segments. Pullback of the catheter across the left ventricular outflow tract (LVOT) and aortic valve demonstrated a pressure gradient approaching 80 mmHg. Echocardiography showed severe obstruction of the LVOT and moderate mitral regurgitation due to a sigmoid septum with basal septal and obvious systolic anterior motion (SAM) of the mitral valve. Three weeks later, elective coronary angiography showed normal left ventricular function and a reduced outflow tract pressure gradient. This was a case of recurrent tako-tsubo cardiomyopathy with LVOT stenosis caused by sigmoid septum.
The psoas abscess is very uncommon during pregnancy. If the abscess is secondary, surgical intervention on the predisposing disease is necessary for better outcome. We report the first case of a psoas abscess complicating Crohn’s disease during ongoing pregnancy. A 28-year-old gravid woman with a history of ileal Crohn’s disease presented at 16 weeks of gestation with high fever, right lower quadrant and low back pain. A diagnosis of right multilocular psoas abscess was made by MRI. Due to the impossibility of drainage and surgical intervention, she was treated by administration of appropriate antibiotics and total parenteral nutrition. The patient transvaginally delivered a female baby at the 40th gestational week without complications. Medical treatment of psoas abscess seems to be a choice in selected cases, although it requires a long hospital stay and continued careful observation due to further risk of infections such as catheter related blood stream infections.